Transient QRS changes simulating myocardial infarction associated with shock and severe metabolic stress

doi:10.1016/0002-8703(67)90081-6

American Heart Journal

Volume 74, Issue 3, September 1967, Pages 402-409

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Abstract

Two patients are presented who, under conditions of shock and severe metabolic stress, manifested transient Q waves in their electrocardiograms simulating myocardial infarction. The absence of clinical features and enzyme elevations as well as the transient nature of the electrocardiographic changes deny the likelihood of true infarction. Other clinical situations associated with this phenomenon are briefly reviewed and the concept of electrically silent areas of myocardium, without cell death, is discussed as an explanation.

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78-Year-old man with nausea and chest pain
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Citation Excerpt :
In several reports, PMI presented with intraabdominal pathologies, such as acute pancreatitis, duodenal perforation, cholecystitis, and perforated appendicitis.20–23 Severe metabolic stress from shock or abnormal renal function has also been implicated.24,25 The underlying mechanism remains under investigation and is thought to be secondary to vagal responses leading to hypotension, decreased coronary perfusion, myocardial depression, increased myocardial oxygen consumption, and subsequent myocardial ischemia with corresponding electrical changes and biomarker elevations.20,26
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Differential diagnosis between acute myocardial infarction (AMI) and an acute surgical abdomen can be difficult. Although the electrocardiogram (ECG) is the most valuable immediate tool in this differential diagnosis, it is crucial to be aware of certain limitations of the ECG under these circumstances. This report describes a patient presenting with electrocardiographic changes consistent with a Q-wave AMI, a perforated duodenal ulcer, and no evidence of AMI or significant coronary artery narrowing at necropsy.
Significance of transient electrocardiographic Q waves in coronary artery disease
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Transient Q waves in the absence of myocardial infarction mayoccur in a variety of circumstances in patients with coronary artery disease. Barring an intraventricular conduction disorder, transient Q waves usually reflect intense but reversible myocardial ischemia, requiring aggressive therapy to salvage myocardium in jeopardy. Q waves may also disappear months or years after a Q-wave myocardial infarction but rarely in the acute or subacute phase. Transient Q waves have assumed greater importance because of the current therapy of myocardial infarction and ischemia with thrombolytic agents, angioplasty, and coronary bypass surgery.
Transient “pathological” Q-waves occurring during exercise testing: Assessment of their clinical significance in a presentation of a series of patients
1987, Journal of Electrocardiology
Exercise-induced Q-waves were encountered in four Caucasian males presenting to the Cardiac Clinic, Tygerberg Hospital, with chest pain suggestive of angina pectoris. This phenomenon occurred in four out of a total of 1943 patients undergoing treadmill stress testing (Bruce Protocol) during a two-year period, giving an incidence of 0.21 percent of this ECG response. Two of the four patients (cases 1 and 2) were documented to have coronary atherosclerosis by selective coronary arteriography. One of these patients may well have been experiencing coronary vasospasm. One of the remaining two patients was a teenager whose exercise response was probably normal, whilst the last patient could have had ischemic heart disease (IHD).
This most interesting and rare response to exercise (stress) testing is discussed, emphasis being placed on its incidence, mechanism and clinical significance in IHD and other conditions in clinical practice. Awareness of the occasional transient nature of “pathological” Q-waves, whether these occur at rest or during exercise, has an important bearing on such acute therapeutic interventions as intracoronary thrombolysis and percutaneous transluminal coronary angioplasty.
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1986, Progress in Cardiovascular Diseases
Transient pathologic Q waves during acute ischemic events: An electrocardiographic correlate of stunned but viable myocardium
1983, American Heart Journal

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¹: Present address. Veterans Administration Hospital, 50 Irving Street, N.W. Washington, D. C., 20422.

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Case reportTransient QRS changes simulating myocardial infarction associated with shock and severe metabolic stress

Abstract

Am. Heart J.

Am. J. Cardiol.

Am. Heart J.

Am. Heart J.

Lancet

Am. Heart J.

Am. Heart J.

Case report
Transient QRS changes simulating myocardial infarction associated with shock and severe metabolic stress